erik steele

ERIK STEELE

Motivating behavior change — it’s time to give up nagging

I spend so much of my time nagging patients to take better care of themselves that they probably think my specialty is bitchingologist. When I’m on a roll listing the litany of health horrors that will befall those who fail to do as I tell them I am scarier than Stephen King and harder to argue with than King Kong. The tide would not come in if I told it to stay out and exercise.

Or so I thought. There is growing evidence this old approach to getting patients to live healthier lifestyles (exercise more, eat less, etc.) is usually failing to change what most patients do, and on a national basis is being drowned by a rising tide of patient inertia and obesity. Few of the patients who physicians urge to exercise at least five times per week actually do so. Fewer still are eating the recommended five servings of fruits and vegetable per day. Physician nagging — what we thought was the penicillin of our persuasion armamentarium — turns out to work like eye of newt.

Few but newts would care about that but for this little problem: By some estimates, 40 percent of a patient’s health status determined by his or her lifestyle, much more than is determined by their medical care. If physicians are largely ineffective convincing patients to stop living unhealthy lifestyles, it means they are largely ineffective treating the most important “disease” most of us have.

This ugly paradox — that despite how good our health care system is at treating many things we are lousy at treating what primarily ails America and Americans — has led many in health care to begin dumping the fundamental nag and scare model for convincing patients to change. One alternative that shows promise is called motivational interviewing, a profoundly different approach that requires new roles for patients and their caregivers in change discussions.

Motivational interviewing is a structured discussion designed to help motivate the patient to change. It contains specific components, including “the change talk,” in which the patient identifies their own desire and need for change, reasons for wanting change, their ability to change, and finally, their personal commitment to change. It seeks to identify the patient’s ambivalence about change, which is defined as the discrepancy between how important they feel the change is and how confident they are in their ability to be successful making changes.

With that ambivalence identified, the interviewer then works with the patient on identification of steps the patient feels they can take that would reduce their ambivalence to change, and thereby lower their personal threshold to action. Finally, the patient and health care provider summarize the results of the discussion and come up with a plan, including specific follow up in the near future to see how the patient is doing implementing the change plan.

This makes what I have been doing with the nag, nag, nag approach look like the application of leeches by comparison. Motivational interviewing is patient-centered, designed to find what would motivate the patient to change taking steps they identify, for reasons that are theirs. It has structure, intent, and a growing body of evidence from studies of the approach that it actually works. My old way, while motivated by my concern for the patient, was largely about my trying to motivate the patient with fear to do the things I suggested, for reasons I identified, using steps I recommended. That approach needs to be replaced by motivational interviewing and other techniques based on actual science of motivating human behavior change in lifestyle.

If motivational interviewing is to have a real effect, however, it cannot simply be a way for health care providers to talk with patients. Such a limited application would be insufficient to the task of changing the downward trajectory of the health of more than 200 million overweight, relatively sedentary Americans. We all need to change from being a nation of naggers to a nation of motivational interviewers, to adopt this technique for the conversations inside our own heads about motivating ourselves, and inside our own homes to motivate those we love.